Citation Nr: 1517822 Decision Date: 04/24/15 Archive Date: 05/04/15 DOCKET NO. 10-08 215 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for liver disease to include hepatitis C and cirrhosis, as secondary to a service-connected disorder for purposes of accrued benefits or for substitution. 2. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or being housebound for the purposes of accrued benefits or for substitution. 3. Entitlement to service connection for cause of the Veteran's death. REPRESENTATION Appellant represented by: Jodee C. Kayton, Attorney at Law ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1968. He died in July 2011 and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. By a rating action dated in December 2008, the RO denied the Veteran's attempt to reopen his claims of entitlement to service connection for bilateral hearing loss and service connection for a right ankle. Subsequently, in a February 2009 rating action, the RO denied the claims of entitlement to service connection for residuals of head trauma, and a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). The Veteran perfected a timely appeal of these decisions. The Board notes that the December 2008 rating action also denied the Veteran's attempt to reopen his claims of entitlement to service connection for a low back disorder, service connection for a right knee disorder, service connection for a left knee disorder, service connection for residuals of fracture of the left ankle and service connection for hepatitis C with cirrhosis. He perfected a timely appeal to that decision. However, in a statement dated in March 2011, the Veteran's attorney indicated that they were withdrawing the issues of service connection for a low back disorder, right knee disorder, left knee disorder, residuals of fracture of the left ankle, and hepatitis C. In April 2011, the RO received the Veteran's supplemental claim (VA Form 21-526B) seeking a number of new claims, to include service connection for his liver disease as secondary to a service-connected disorder, to include malaria. Unfortunately, the Veteran passed away before a decision could be made regarding his appeal. Following the Veteran's death, the appellant filed a claim for Dependency and Indemnity Compensation (DIC), death pension, and accrued benefits that were received by the RO in August 2011. In August 2011, the appellant also requested that she be substituted as the claimant in the Veteran's claims pending before the Board. By a rating action dated in October 2012, the RO denied the claims of service connection for malaria, accrued benefits; service connection for liver disease to include hepatitis C and cirrhosis secondary to malaria, accrued benefits; service connection for chronic kidney disease secondary to malaria, accrued benefits; service connection for blood disorders, accrued benefits; service connection for COPD secondary to malaria, accrued benefits; service connection for congestive heart failure secondary to malaria, accrued benefits; service connection for peripheral neuropathy, accrued benefits; special monthly compensation based on need aid and attendance or housebound status, accrued benefits; and service connection for cause of death. In her notice of disagreement, received in January 2013, the appellant disagreed with the denial of service connection for the cause of the Veteran's death, accrued benefits for service connection for peripheral neuropathy due to Agent Orange exposure, accrued benefits for service connection for heart disease due to Agent Orange exposure, accrued benefits for special monthly compensation based on the need for aid and attendance or by reasons of housebound. A statement of the case was issued in April 2013. In her substantive appeal (VA Form 9), received in June 2013, she only appealed the issues of entitlement to accrued benefits for service connection for congestive heart failure due to Agent Orange exposure, accrued benefits for special monthly compensation based on the need for aid and attendance or by reasons of being housebound, and service connection for the cause of the Veteran's death. In a statement dated in September 2013, the appellant submitted a timely notice of disagreement with the portion of the October 2012 rating action denying accrued benefits for service connection for liver disease, to include hepatitis C and cirrhosis, as secondary to a service-connected disorder. In November 2013, the Board reopened the Veteran's claim for entitlement to service connection for hearing loss, granted entitlement to service connection for a right ear hearing loss, and denied entitlement to service connection for left ear hearing loss. In addition, the Board reopened and granted the claim for entitlement to service connection for a right ankle disorder, denied entitlement to service connection for congestive heart failure, and further denied a rating in excess of 50 percent for PTSD. The issues of entitlement to service connection for residuals of head trauma, accrued benefits; entitlement to service connection for the cause of the Veteran's death, and entitlement to SMC based on the need for aid and attendance or being housebound, accrued benefits, were remanded for further evidentiary development. The appellant has since perfected her appeal for the claim for accrued benefits for service connection for liver disease, to include hepatitis C and cirrhosis, and, as such, it is now before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of entitlement to SMC based on the need for aid and attendance or being housebound for the purposes of accrued benefits or for substitution is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's alcoholism has been shown to be secondary to his service-connected PTSD. 2. Competent medical evidence of record is in equipoise as to whether the Veteran's end stage liver disease to include hepatitis C and cirrhosis, was caused or aggravated by his alcoholism. 3. The Veteran's death certificate shows that he died in July 2011 and the immediate cause of his death was listed as end stage liver disease. 4. At the time of the Veteran's death, he was service-connected for PTSD, rated as 50 percent disabling; and bilateral tinnitus, rated as 10 percent disabling. 5. Resolving all doubt in favor of the appellant, the Veteran's PTSD with alcoholism combined with other factors to cause death, and aided or lent assistance to the production of death. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for liver disease, to include hepatitis C and cirrhosis, have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2014). 2. The criteria for entitlement to service connection for the cause of the Veteran's death have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1310, 5103, 5103A, 5107 (West 2014), 38 C.F.R. §§ 3.159 , 3.303, 3.307, 3.309, 3.312 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION In light of the fully favorable determination in this case, no further discussion of compliance with VA's duty to notify and assist is necessary. Service Connection Prior to his July 2011 death, the Veteran maintained that his liver disease was secondary to his malaria. The appellant also maintains that the Veteran's malaria contributed to his end stage liver disease. In addition, the appellant contends that the Veteran self-medicated with alcohol to help cope with his posttraumatic stress disorder (PTSD) symptoms, which developed due to his combat experiences, and the traumatic events he was exposed to, in Vietnam. According to the appellant, the Veteran's treatment records reflect that the Veteran's excessive drinking led to the development of his liver cirrhosis, which contributed and resulted in his subsequent liver disease. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection to be granted, generally there must be (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2014); see Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Although the law provides that no compensation shall be paid if the disability for which service connection is sought is a result of the Veteran's own willful misconduct or abuse of alcohol or drugs, the statute does not preclude compensation for an alcohol abuse disability secondary to a service-connected disability. Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001); 38 U.S.C.A. §§ 105(a),1110. Instead, the law precludes compensation for "primary" alcohol abuse disabilities and for secondary disabilities (such as cirrhosis of the liver) that result from primary alcohol abuse. Id. at 1376. "Primary" means an alcohol abuse disability arising during service from voluntary and willful drinking to excess. Id; see also 38 U.S.C.A. § 105(a). The cases where service connection may be granted and compensation paid for an alcohol abuse disability are quite limited. Allen, 237 F.3d at 1381. Service connection and compensation may only be granted if such Veterans can "adequately establish that their alcohol . . . disability is secondary to or is caused by their primary service-connected disorder." Id. "[S]uch compensation would only result 'where there is clear medical evidence establishing that the alcohol . . . disability is indeed caused by a Veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing.'" Id. Also, organic disease and disabilities which develop secondary to the chronic use of alcohol, or drugs, or develop due to infections resulting from drug injections will not be considered of willful misconduct origin. See 38 C.F.R. § 3.301(c)(2). Prior to his death, the Veteran was service-connected for PTSD, which was evaluated as 50 percent disabling. Review of the record reflects that the Veteran died in July 2011, and his immediate cause of death, as listed on his death certificate, was end stage liver disease. The appellant is the Veteran's surviving spouse and she essentially contends that the Veteran developed liver cirrhosis, which contributed to the development of his end stage liver disease, as a result of his alcohol abuse, which was secondary to his service-connected PTSD. VA treatment records dated prior to the Veteran's death reflect that he had a history of heavy alcohol abuse. During his April 2001 VA psychiatric examination, the Veteran stated that since his experiences in Vietnam, he had a marked degree of difficulty with many situations in his life, including two failed marriages, multiple jobs secondary to "difficulty getting along with people," and excessive use of alcohol and drugs. VA treatment records dated in February 2005 reflect that the treatment provider noted that the Veteran had a past medical history significant for liver cirrhosis from hepatitis C and alcohol usage. During the February 2005 VA examination, the Veteran stated that he quit drinking alcohol several years prior. Report of the July 2006 VA consultation reflects that the Veteran had a history of heavy alcohol use. A June 2007 Nursing Outpatient note reflects that the Veteran received counseling about the physical problems that can result from too much alcohol in any form. At a November 2008 VA treatment visit, the Veteran indicated that he quit drinking alcohol in April - May 2006. At the October 2009 VA examination, the VA examiner noted that the Veteran stopped drinking heavily many years prior, but had a strong history of alcoholism. In a statement dated in August 2011, P.W., M.D. stated that the Veteran was a patient of the hospice program; he noted that end stage liver cirrhosis and Agent Orange were contributing factors to his demise. In an August 2011 VA treatment report, the VA physician stated that he explained to the appellant that from a medical standpoint, the Veteran's liver failure was from his chronic hepatitis C, which can be attributed to numerous causes such as tattoos, needle stick, blood transfusion, and intravenous drug use, etc. Pursuant to the November 2013 Board remand, the Veteran's claims file was referred to a VA examiner to provide an opinion as to whether the Veteran's death from end stage liver disease was related to his military service, to include his malaria or herbicide exposure. In a March 2014 VA medical opinion, the VA reviewer determined that the liver disorder causing or contributing to the Veteran's death is less likely as not caused by, a result of, or related to any disease or injury incurred during service, to include his malaria or herbicide exposure. According to the VA reviewer, the Veteran was an adult lifetime alcoholic, and the most likely cause of his liver disease was from his alcohol abuse. The Veteran's claim was remanded once again to determine whether the Veteran began using alcohol to help deal with his PTSD, and if so: (1) whether his PTSD-related alcohol abuse contributed to and/or caused his end-stage liver disease and subsequent death; or (2) whether the Veteran's liver disease was aggravated by his PTSD-related alcohol abuse. In a September 2014 VA medical opinion, the VA reviewer determined that it is at least as likely as not that the Veteran's liver disease was caused by his hepatitis C. According to this VA reviewer, the March 2014 VA reviewer's assessment was predominantly based on the appellant's self-reported history, rather than on the objective evidence of record. According to the September 2014 VA reviewer, the medical evidence reflected that the Veteran was diagnosed with end stage liver disease due to his cirrhosis which was due to his hepatitis C, and he could not find any clear medical evidence of alcohol abuse in the medical records reviewed. As such, the VA reviewer determined that an opinion regarding alcohol abuse was not clinically indicated. The appellant subsequently submitted a medical opinion dated in November 2014, and issued by G.U., a nurse practitioner and certified VA compensation and pension examiner. In her opinion, G.U. took into account the Veteran's claims file, to include his military records, his post-service VA and private treatment records, the appellant's lay statements, and VA examination reports. G.U. also referenced and provided numerous medical literature and journals articles which addressed the interrelationship between PTSD and substance abuse in Vietnam veterans. Based on her review of the evidence, as well as her understanding of the medical and psychological principles as they currently stood, G.U. opined that the Veteran's end stage liver disease (to include his chronic hepatitis C and cirrhosis) was more likely than not secondary, related to, and/or aggravated by his military service-connected PTSD. In reaching this opinion, G.U. recognized that the Veteran had a formal diagnosis of hepatitis C that had been substantiated via laboratory studies, as well as a formal diagnosis of Laennec's Cirrhosis which is associated with chronic alcohol abuse and alcoholism. G.U. also noted that the record reflected clear documentation of alcohol abuse, and the Veteran had a formal diagnosis of PTSD with evidence of severe symptomatology during his post-Vietnam lifetime that is known to promote high risk behaviors and substance abuse to help avoid the associated symptomatology. G.U. specifically found that the Veteran's claims file revealed documentation of substance use and abuse throughout his post-Vietnam lifetime, to include the excessive usage of alcohol, as well as a remote history of intravenous (IV) heroin, cocaine, and marijuana usage. G.U. also took into account the appellant's lay assertions indicating that the Veteran never gave up drinking completely, despite stating to his medical providers that he had for fear that the VA would discontinue his medical care if it was known he was still abusing alcohol. According to G.U., the Veteran exhibited many associated physical manifestations and sequelae directly related to his chronic severe alcohol abuse and ingestion, including elevated liver function laboratory studies, grade 2-3 distal esophageal varices and a gastric-antral ulcer per EGD. G.U. also relied on the medical literature articles which reflected that alcohol and substance abuse are highly associated with the development of Laennec's cirrhosis, and a known symptom of PTSD. In light of these findings and the medical literature articles which highlighted the correlation between PTSD and alcohol and drug use, G.U. determined that the Veteran's history of PTSD with severe symptomatology directly resulted and contributed to his chronic alcoholism condition, which in turn, caused his cirrhosis and his history of hepatitis C. Based on the medical evidence of record, the Board finds that the Veteran's alcohol abuse throughout his life was secondary his service-connected PTSD, and not a result of willful misconduct. Upon review of the record, the Board finds that there is a legitimate difference of opinion from a medical standpoint as to the cause and origin of the Veteran's end stage liver disease. Unfortunately, the Board does not find the September 2014 VA medical opinion to be an adequate one. Indeed, in reaching his conclusion, the September 2014 reviewer predominantly relied on a mistaken understanding of the medical evidence of record, which according to him, was absent any signs of alcohol abuse. The September 2014 VA reviewer discounted the relevance of the March 2014 VA opinion, noting that this reviewer based his conclusion (that the Veteran's liver disease was due to his alcohol abuse) on the appellant's self-reported history, rather than on the objective evidence. However, this is an incorrect assessment because, as discussed above, the medical evidence throughout the Veteran's post-service years reflected a history of alcohol use, which he himself attributed to his PTSD. The Veteran noted to have quit using alcohol sometime between 2005-2006, which suggests a history of somewhat heavy alcohol use. Indeed, a number of VA treatment records dated in February 2005 attributed the Veteran's liver cirrhosis, in part, to his alcohol abuse. As such, the Board finds that the September 2014 VA reviewer did not base his opinion on an accurate factual premise, and therefore, the opinion provided is not probative. To that end, the Board places more weight on the November 2014 opinion issued by G.U. In her opinion, G.U. had the opportunity to review the Veteran's medical records in detail, to include all the records reviewed by the other VA reviewers, and along with the March 2014 reviewer, she also found that the Veteran's end stage liver disease was due to, and aggravated by, his history of alcohol abuse, which she attributed to his service-connected PTSD. In reaching her conclusion, G.U. not only provided an extensive rationale in support of the opinion reached that included references to pertinent medical literature articles, but she also addressed why the September 2014 VA opinion was erroneous and inadequate. Although the August 2011 VA physician attributed the Veteran's end stage liver disease to his hepatitis C, her assessment did not include a thorough review of the Veteran's claims folder, and thus did not take into consideration the Veteran's history of heavy alcohol abuse. Moreover, the November 2014 VA reviewer also determined that the Veteran's hepatitis C was secondary to his service-connected PTSD, noting that the medical literature documents that alcohol and substance abuse is highly associated with the contraction of hepatitis C. In a claim for VA benefits, "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Gilbert, 1 Vet. App. at 54. Entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine, when the evidence is in "relative equipoise, the law dictates that the Veteran prevails." Id. Based on the foregoing, the Board finds that there is reasonable doubt as to whether the Veteran's end stage liver disease is due, in part to his alcohol abuse, which has been found to be secondary to his PTSD. To the extent that there is reasonable doubt, that doubt will be resolved in the appellant's favor. Accordingly, the Board finds that the Veteran's PTSD and subsequent alcoholism combined with other factors did contribute to the development of his end stage liver disease. As such, service connection for end stage liver disease is warranted. Cause of Death The death of a veteran will be considered as having been due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). A principal cause of death is one which, singularly or jointly with some other condition, was the immediate or underlying cause of death, or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributes substantially or materially to death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). Service-connected disabilities or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there was resulting debilitating effects and general impairment of health to the extent that would render the person less capable of resisting the effects of either disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of co-existing conditions, but, even in such cases, there is for consideration whether there may be reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. 38 C.F.R. § 3.312(c)(4). As noted above, the appellant essentially contends that the Veteran's longstanding alcohol abuse was associated with his service-connected PTSD, and that his alcoholism led to the development of his end stage liver disease and subsequent death. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection for the cause of the Veteran's death is warranted. At the time of the Veteran's death, the Veteran was service-connected for PTSD and bilateral tinnitus. As discussed above, the appellant has contended that the Veteran began drinking alcohol as a way to cope with his PTSD symptoms, and his history of alcohol abuse contributed and led to the development of his end stage liver disease which was the immediate cause of his death. As discussed above, the November 2014 VA reviewer, G.U., concluded that the Veteran's end stage liver disease (to include chronic hepatitis C and liver cirrhosis) was more likely than not secondary to his service-connected PTSD. G.U. determined that the Veteran developed cirrhosis of the liver as a result of his alcoholism, which was a direct result of his PTSD. In reaching this opinion, G.U. not only reviewed the Veteran's claims file and took into account his history of alcohol abuse throughout his post-service years, but also referenced a number of medical literature articles, all of which highlighted the increased risk of alcohol abuse among veterans with PTSD. Given the evidence of record, the Board finds that service connection for the cause of the Veteran's death is established. At the time of the Veteran's death, he was service-connected for PTSD and evidence has established that the Veteran's alcoholism was secondary to his PTSD. Furthermore, as stated by the November 2014 reviewer, the evidence reflects that the Veteran's alcoholism contributed to the development of his liver cirrhosis, and thus his end stage liver disease, which was the immediate cause of his death. The Board acknowledges that there is evidence that indicates the Veteran's end stage liver disease was not a result of his PTSD and resulting alcoholism and death. However, the Board finds that the evidence is at least in equipoise as to whether the Veteran's PTSD with alcoholism was a contributing cause of death; evidence indicates alcohol contributed to the development of his liver cirrhosis which led to his end stage liver disease. In light of the medical evidence recounted above, the fact that the Board has already granted the appellant's claim of service connection for end stage liver disease as secondary to a service-connected disability, and given that end stage liver disease was listed as the immediate cause of the Veteran's death, the Board finds that the Veteran's service-connected PTSD with resulting alcoholism is shown to have combined with other factors to cause death, and aided or lent assistance to the production of death. After resolving all reasonable doubt in the appellant's favor, the Board finds that service connection for the cause of his death is established. See 38 C.F.R. § 3.102. ORDER Entitlement to service connection for end stage liver disease, for accrued benefits purposes, is granted. Entitlement to service connection for the cause of the Veteran's death is granted. REMAND Prior to his death, the Veteran had filed a claim for special monthly compensation based on a need for aid and attendance or on account of being housebound. At the January 2011 examination for housebound status or permanent need for regular aid and attendance, the VA examiner diagnosed the Veteran with end stage hepatic failure and peripheral neuropathy. Although it was noted that the Veteran could feed himself, the examiner indicated that he could not prepare his own meals, and needed assistance when bathing and tending to other hygiene needs, adding that the Veteran was very unsteady on his feet. The Veteran was not found to be legally blind or in need of nursing home care, but when asked whether he required medication management, the examiner marked that he did, and commented that his wife assisted him with this. The examiner described the Veteran as having generalized weakness and "Abd. Ascitis" and noted that the Veteran exhibited symmetrical upper extremity strength with prior fine motor skills. When asked to describe the restrictions of each lower extremity with particular reference to the extent of limitation of motion, atrophy, and contracturesor other interference, the examiner noted that the Veteran exhibited generalized weakness and used a cane to help him ambulate. All other exhibited pathology was shown to be poor balance, and intermittent unpredictable confusion. When asked how often per day or week the Veteran could leave the home or immediate premises, the examiner noted that the Veteran was homebound, and assisted fully by his wife for medical appointments. When asked whether aids such as canes, braces, crutches, or the assistance of another person was required for locomotion, the examiner marked yes, and added that the Veteran could travel a distance of one block. In a subsequent statement, dated in May 2015, the Veteran stated that in addition to the numerous medical conditions for which he was receiving treatment for, he also suffered from peripheral neuropathy which left him with little to no feeling in his feet. According to the Veteran, as a result of his neuropathy, he avoided lifting his feet, and instead shuffled side to side when he walked. The Veteran further noted that he was dependent on his wife to help him get in and out of the shower, and to help him get up out of the shower seat the VA had supplied him with. In another statement, the Veteran wrote that he has a difficult time doing things on his own without the help of his wife, predominantly because he could feel his feet. The need for aid and attendance is defined as helplessness or being so nearly helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.351(b) (2014). A veteran will be considered in need of aid and attendance if he is (1) blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance. 38 C.F.R. §§ 3.351(c), 3.352(a) (2014). Under 38 C.F.R. § 3.352(a), the following criteria will be accorded consideration in determining the need for regular aid and attendance: the inability of a claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without such aid, such as supports, belts, lacing at the back, etc.); the inability of a claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. It is not required that all of the disabling conditions enumerated be found to exist before a favorable ruling may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the Veteran is so helpless as to be in need of regular aid and attendance will not be based solely on an opinion that the Veteran's condition is such that it would require him to be in bed. It must be based on the actual requirements of personal assistance from others. 38 C.F.R. § 3.352(a); Turco v. Brown, 9 Vet. App. 222, 224 (1996). Housebound benefits are warranted if, in addition to having a single permanent disability rated 100 percent disabling under the VA Schedule for Rating Disabilities, the Veteran: (1) has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or, (2) is "permanently housebound" by reason of disability or disabilities. This requirement is met when the Veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1502(c) (West 2014); 38 C.F.R. § 3.351(d). Although the January 2011 VA examiner determined that the Veteran required aid and assistance when bathing, tending to various hygiene needs, when leaving the home or immediate premise, and for locomotion purposes, this finding was made based on the Veteran's diagnoses of end stage hepatic failure and peripheral neuropathy. Indeed, it was noted that the Veteran was unsteady, had poor balance, exhibited generalized weakness, and used a cane to ambulate as a result of his peripheral neuropathy. In a number of statements, the Veteran indicated that he relied on his wife due to his inability to walk comfortably as a result of his peripheral neuropathy. Although the claim for service connection for end stage liver disease has been granted herein, the Veteran was never service-connected for peripheral neuropathy prior to or after his death. As such, the Board is unclear as to whether entitlement to SMC based on the need for aid and attendance and/or housebound status should be granted for accrued benefits solely for the Veteran's now service-connected end stage liver disease. Moreover, the Board is unclear as to whether the appellant has established a factual need for aid and attendance pursuant to the criteria under 38 C.F.R. § 3.352(a) (2014). In light of these questions, the Board finds that additional development is required, and the claim for SMC should be remanded once again to obtain an addendum medical opinion regarding whether the Veteran required regular aid or attendance or was housebound prior to his death as a result of his service-connected disabilities. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The RO must contact the appellant and afford her the opportunity to identify or submit any additional pertinent evidence in support of the claim on appeal. Based on her response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. If, after making reasonable efforts to obtain this information the RO is unable to secure any of the identified records, the RO must notify the appellant and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the appellant is ultimately responsible for providing information. The appellant must then be given an opportunity to respond. 2. Then, the RO should obtain a medical addendum opinion that addresses whether the Veteran was in need of regular aid or attendance or was housebound prior to his death in July 2011. The claims file and all electronic records must be made available to a VA examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. Following a review of the evidence of record, the examiner must indicate whether the Veteran's service-connected disabilities acting together resulted in the Veteran being housebound or in need of regular aid and attendance of another person prior to his death. In reaching these conclusions, the examiner must address the following: a. Whether as a result of the Veteran's service-connected disabilities, he was substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical area prior to his death, and it is reasonably certain that the disability or disabilities and resultant confinement would have continued for the remainder of his life. b. Whether as a result of the Veteran's service-connected disabilities, prior to his death, he had the (1) inability to dress or undress himself or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability could not be done without aid; (3) inability of the Veteran to have fed himself through loss of coordination of his upper extremities or through extreme weakness; (4) inability of the Veteran to attend to the wants of nature; or (5) presence of incapacity, either physical or mental, which required care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. Finally, after undertaking any other development deemed appropriate, the RO must readjudicate the issue on appeal. If any benefit sought is not granted, the RO must furnish the appellant and her attorney with a supplemental statement of the case and afford her an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs